CONSORT RANDOMIZED CLINICAL TRIAL

Chafic Safi, DMD, MS,

Outcome of Endodontic Meetu R. Kohli, BDS, DMD,
Samuel I. Kratchman, DMD,
Microsurgery Using Mineral Frank C. Setzer, DMD, PhD, MS,
and Bekir Karabucak, DMD, MS
Trioxide Aggregate or Root
Repair Material as Root-end
Filling Material: A Randomized
Controlled Trial with
Cone-beam Computed
Tomographic Evaluation

ABSTRACT
SIGNIFICANCE
Introduction: The purpose of this randomized clinical trial was to evaluate healing after
endodontic microsurgery (EMS) using mineral trioxide aggregate (MTA) versus There is no significant
EndoSequence root repair material (RRM; Brasseler, Savannah, GA) as root-end filling difference in the outcomes of
materials. Methods: Two hundred forty-three teeth with persistent or recurrent apical endodontic microsurgery
periodontitis were randomly assigned to either the MTA or RRM group. EMS was performed, when MTA and RRM are used
and follow-up visits with clinical and radiographic investigation were scheduled at 6, 12, and as root-end filling materials
24 months with follow-up cone-beam computed tomographic (CBCT) imaging after 12 evaluated by radiograph and
months. Results: One hundred twenty teeth with an average follow-up of 15 months were cone-beam computed
evaluated. The overall success rate was 93.3% for periapical (PA) evaluation and 85% for tomographic imaging.
CBCT evaluation. The RRM group exhibited 92% and 84% success rates as assessed on PA
and CBCT imaging, respectively. The MTA group exhibited 94.7% and 86% success rates as
assessed on PA and CBCT imaging, respectively. No significant difference was observed
between the 2 groups. Microsurgical classification, root canal filling quality, root-end
filling material depth, and root fracture were found to be significant outcome predictors.
Conclusions: EMS is a predictable procedure with successful outcome both 2-dimensional
and 3-dimensional radiographic evaluation when RRM or MTA was used as the root-end filling
material. (J Endod 2019;-:1–9.)

KEY WORDS
Cone-beam computed tomography; endodontic microsurgery; EndoSequence root repair
material; mineral trioxide aggregate; outcome; prognostic factors From the Department of Endodontics,
University of Pennsylvania School of
Dental Medicine, Philadelphia,
Persistent and recurrent apical periodontitis can be treated predictably by modern endodontic surgery. Pennsylvania
Unlike traditional surgery, modern microsurgical techniques incorporate the use of an operating
Address requests for reprints to Dr Bekir
microscope; ultrasonic tips for precise root-end preparation; and biocompatible root-end filling materials Karabucak, Department of Endodontics,
such as Super EBA (Harry J Bosworth Co, Skokie, IL), mineral trioxide aggregate (MTA), and more University of Pennsylvania, 240 S 40th
recently other bioceramic-based materials such as Endosequence Root Repair Material (RRM; Brasseler, Street, Philadelphia, PA 19104.
Savannah, GA) for better seal and apical tissue response1,2. Weighted pooled success rates have been E-mail address: bekirk@mac.com
0099-2399/$ - see front matter
established in a meta-analysis with cumulative outcomes for the traditional approach at 59.0% and for
endodontic microsurgery (EMS) at 93.5%2. The significantly higher success of the modern microsurgical Copyright © 2019 Published by Elsevier
Inc. on behalf of American Association of
procedure has been repeatedly concluded in several investigations3–5.
Endodontists.
An ideal root-end filling material should be biocompatible, dimensionally stable, bactericidal, or https://doi.org/10.1016/
bacteriostatic; easy to handle; and provide an excellent seal6. MTA (ProRootMTA; Dentsply Tulsa j.joen.2019.03.014

JOE  Volume -, Number -, - 2019 Endodontic Microsurgery Using MTA and RRM 1
Dental, Tulsa, OK) has been the material of MATERIALS AND METHODS Preoperative Procedures
choice. It contains tricalcium silicate, Patients were informed about the potential risks
Study Design and Ethics
dicalcium silicate, bismuth oxide, and small of and alternatives to EMS. Written and verbal
A noninferiority randomized controlled trial was
proportions of tricalcium aluminate and informed consent were acquired. A PA
conducted to compare the surgical outcome of
calcium sulfate. The composition is similar to radiograph (CS 2100; Carestream Dental,
MTA (the control group) and RRM (the test
that of Portland cement with added bismuth Atlanta, GA) and CBCT image of the tooth were
group). Teeth were randomly assigned to the
oxide for radiopacity7. The superiority of the taken. CBCT scans of the patient were acquired
groups using an online randomization program
material, sealability, exemplary by 1 of the following machines available in the
developed by the information technology
biocompatibility, cementogenesis, endodontic department at the time of treatment:
department of the University of Pennsylvania,
reconstitution of the periodontal ligament at
Philadelphia, PA. The study protocol was 1. From July 2011 to February 2013,
the resected root surface, and clinical
approved by the ethics committee of the SUNI3D (Suni Medical Imaging, San
prognostic superiority over others has been
Institutional Review Board of the University of Jose, CA): field of view (FOV) 5 5 ! 5
corroborated in various studies8–10. Despite
Pennsylvania (institutional review board number: cm, voxel size 5 0.08 mm
these biological advantages, MTA exhibits
815114). The minimum sample size was 2. February 2013 to April 2014, CS 9000
difficult handling characteristics because of
determined to be 124 (62 in each group) based 3D (Carestream Dental): FOV 5 7.5 !
its granular consistency and long setting
on a 20% mean difference in outcome between 3.7 cm, voxel size 5 0.076 mm
time11. It has also been reported to cause
the groups and power 5 0.80 (P , .05). The 3. After April 2014, Veraviewepocs 3D
discoloration of the surrounding tooth
subjects were recruited during the planned time R100 (Morita, Irvine, CA): FOV 5 4 !
structure12.
frame for the study at the Department of 4 cm, voxel size 5 0.125 mm
Recently, other calcium silicate–based
Endodontics, University of Pennsylvania Dental
materials have been introduced in A surgical evaluation form was used to
School from July 2011 to May 2014.
endodontics to overcome these limitations. identify any preoperative prognostic factors
RRM is a bioceramic-based material that is including patient sex, presurgical apical
available as a premixed moldable putty. diagnosis as per American Association of
Subject Enrollment and Inclusion/
Several in vitro studies have shown RRM to Endodontists consensus, treatment rendered
Exclusion Criteria
be similar in characteristics to MTA13,14. before surgery (primary or secondary root canal
Consecutive patients presenting to the
RRM and MTA have also been evaluated in therapy), tooth position (anterior vs posterior,
Department of Endodontics for routine
a dog model with periapical (PA) film, cone- maxilla vs mandible), microsurgical classification
planned root-end surgery were evaluated for
beam computed tomographic (CBCT) from PA radiographs (A, B, or C), presence of a
inclusion in the study.
imaging, micro–computed tomographic broken instrument in the affected root(s) seen
The inclusion criteria were as follows:
imaging, and histologically15. Both materials on PA and CBCT imaging, and root canal filling
performed equally well with a minimal or no 1. Age 18 years and older consenting to quality evaluated on PA radiography. The
inflammatory response noted histologically. the surgical procedure as well as quality of root canal filling was evaluated by the
It was observed that RRM and MTA agreeing to preoperative and at least 1 criteria established by Chugal et al18. A root
displayed equivalent healing with PA follow-up CBCT evaluation after 12 canal filling was considered adequate when it
radiographs; however, on CBCT and micro– months exhibited a homogeneous radiopaque area with
computed tomographic images, RRM 2. Noncontributory medical history no visible voids or space between the material
showed superior healing tendency at the (American Society of Anesthesiologists and the walls of the canal or within the body of
resected root surface and the PA area. A class I and II) the material itself. Root canal fillings that did not
clinical retrospective study evaluating RRM 3. A history of previous endodontic show a uniform radiodensity and/or with canal
as root-end filling material analyzing clinical treatment with radiographic presence space visible laterally and apically were
and PA radiographic outcome at a of apical periodontitis considered inadequate. Root canal filling length
minimum of a 1-year follow-up showed a 4. A true endodontic lesion: microsurgical was evaluated on PA radiographs. The quality
success rate of 92% with no prognostic classification A, B, or C (Fig. 1)1 of root canal filling length was evaluated by
indicators16. A prospective randomized 5. Lesion size less than 10 mm in diameter evaluation criteria suggested by Sjogren et al19.
clinical trial comparing MTA with iRoot BP
The exclusion criteria were defined as A root canal filling ending 0–2 mm from the
plus, a material similar to RRM, at a 12- radiographic apex was considered adequate.
follows:
month radiographic follow-up corroborated Any root canal filling not within that range (short
success rates of 93% and 94%, 1. Nonconsenting patients and patients or long) was considered inadequate. The
respectively, with no significant difference in younger than 18 years of age presence or absence of fenestration of the
outcome17. 2. Medical history with American Society cortical buccal plate and the height of the
The aim of the current investigation was of Anesthesiologists class III to V cortical plate (evaluated on CBCT) were
to evaluate the outcome of MTA and RRM as 3. Insufficient coronal restoration documented. Lesion diameter (measured
root-end filling material clinically with 4. Nonrestorability or traumatized teeth on CBCT imaging) in millimeters in
2-dimensional PA radiographs and 5. Teeth with microsurgical classification 3 dimensions and the largest value were
3-dimensional CBCT imaging in a prospective D, E, or F (Fig. 1) recorded (Table 1).
randomized clinical controlled trial. The data 6. Mobility .1
were analyzed to identify prognostic 7. Radiographic presence of nonapical
predictors of the procedure. The null root resorption Surgical Procedure and Material
hypothesis was that there was no significant 8. Resurgery Randomization
difference in the outcome of EMS for MTA or 9. Vertical root fracture All EMS procedures were performed by
RRM. 10. Lesions 10 mm in diameter postgraduate residents under the supervision

2 Safi et al. JOE  Volume -, Number -, - 2019

FIGURE 1 – Preoperative microsurgical classification of teeth.

of faculty and followed the guidelines and same standard protocol. At the root-end filling MTA or RRM group. The information
principles outlined by Kim and Kratchman1. stage, the supervising faculty used the technology department of the university was
Except for the randomization of the root-end University of Pennsylvania Web server for tasked to develop a Web-based Health
filling material, all procedures followed the randomization to assign the teeth to either the Insurance Portability and Accountability Act of
1996–compliant program for randomization.
TABLE 1 - Demographic Distribution of Cases The program is available to all departments via
the university intranet to conduct
Total MTA BCRRM randomization of a clinical trial. The program
can be accessed only with a username and
120 57 63
password; the patient’s chart number was
% (n) % (n) % (n) added to this specific Consolidated
Sex Standards of Reporting Trials trial within the
Male 41.7 (51) 40.4 (23) 44.4 (28) program, and the program randomly picked
Female 58.3 (69) 59.6 (34) 55.6 (35) the material to be used. MTA was assigned a
Preoperative signs and symptoms value of 0, whereas RRM was assigned 1.
Present 55.8 (67) 56.1 (32) 55.5 (35) This allowed for allocation concealment. The
Absent 44.2 (53) 43.9 (25) 44.5 (28) supervising faculty logged into the software,
Broken instrument
and the computer generated the allocation
Present 5 (6) 5.3 (3) 4.5 (3)
sequence of 0 or 1 randomly without any
Absent 95 (114) 94.7 (54) 95.5 (60)
Previous retreament involvement of the operator, the patient, or
Yes 10 (12) 1.6 (8) 6 (4) reviewers. The assistant mixed the material
No 90 (108) 98.4 (49) 94 (59) and handed it over to the operator for use.
Preoperative periapical diagnosis The operator was aware what he or she was
Symptomatic apical periodontitis 70 (84) 77.2 (44) 63.5 (40) using only after it was dispensed to him or her
Asymptomatic apical periodontitis 25 (30) 22.8 (13) 27 (17) during the procedure. The materials were
Chronic apical abscess 5 (6) 0 (0) 9.5 (6) used as per manufacturer instructions. After
Tooth position root-end filling, the surgical site was cleaned
Anterior 30 (36) 22.8 (13) 36.5 (23)
and the flap repositioned. Primary wound
Posterior 70 (84) 77.2 (44) 63.5 (40)
closure was achieved with interrupted sutures
Jaw
Maxilla 45 (54) 47.4 (27) 42.9 (27) as needed (5.0 Supramid nylon sutures; S
Mandible 55 (66) 52.6 (30) 57.1 (36) Jackson Inc, Alexandria, VA). PA radiographs
Microsurgical classification were taken. Patients received postoperative
Class A 47.5 (57) 56 (32) 39.7 (25) instructions and were prescribed an oral
Class B 21.7 (26) 25 (14) 19 (12) analgesic (ibuprofen 600 mg) and instructed
Class C 30.8 (37) 19 (11) 41.3 (26) to rinse twice daily with chlorhexidine 0.2%
Root canal filling quality mouth rinse for 1 week. Antibiotics were
Adequate 46.7 (56) 63.2 (36) 31.7 (20) generally not prescribed unless the patient’s
Inadequate 43.3 (64) 36.8 (21) 68.3 (43)
medical history warranted it. Sutures were
Root canal filling length
removed 3–5 days after surgery.
Adequate 51.7 (62) 61.4 (35) 42.9 (27)
Inadequate 48.3 (58) 38.6 (22) 57.1 (36)
Buccal cortical plate
Follow-up Procedures
Present 44.2 (53) 57.9 (33) 31.7 (20)
All patients were invited back yearly after
Absent 55.8 (67) 42.1 (24) 68.3 (43)
Lesion size periapical surgery for follow-up examination. At
5 mm 68.3 (82) 68.4 (39) 68.3 (43) the follow-up visit, a routine clinical
.5 mm 31.7 (38) 31.6 (18) 31.7 (20) examination with a PA radiograph was
conducted. The tooth was evaluated for
BCRRM, bioceramic root repair material; MTA, mineral trioxide aggregate. symptoms, tenderness to percussion,

JOE  Volume -, Number -, - 2019 Endodontic Microsurgery Using MTA and RRM 3
FIGURE 2 – (A) The Molven radiographic criteria for evaluating teeth after EMS. Complete healing categories. (AA) The lamina dura is restored to the original width. (AB) The lamina
dura is reconstituted but is less than 2 times the width along the resected root surface. (AC) The lamina dura is widened along the root-end filling material. (AD) Complete bone repair;
however, the density of bone in the surgical site is not the same as the surrounding bone. No discernible lamina dura or periodontal ligament at the resected root surface suggesting
ankylosis. (B) The Molven radiographic criteria for evaluating teeth after EMS. Incomplete healing categories. (B-A) The radiolucent area at follow-up has decreased; however, there is a
dense radiolucency present that is asymmetric to the apex, sometimes disassociated from the apex, that presents often with a sunburst bone pattern. (B-B) A dense radiolucent area
not in continuity with the periodontal ligament within the surgical site. (C) The Molven radiographic criteria for evaluating teeth after EMS. Uncertain healing categories. C-A represents
the radiolucency as seen on an immediate postoperative radiograph and (C-B) represents the follow-up. The area has reduced significantly but is still larger than 2 times the original
periodontal ligament space. (D) The Molven radiographic criteria for evaluating teeth after EMS. Unsatisfactory healing categories. D-A represents the radiolucency as seen on an
immediate postoperative radiograph and D-B represents the follow-up. The area has enlarged in size or remains the same.

4 Safi et al. JOE  Volume -, Number -, - 2019

FIGURE 3 – (A) Penn criteria for evaluating 3-dimensional scans of teeth after EMS. Complete healing categories. (AA) Reformation of the periodontal space of normal width and
lamina dura over the entire resected and unresected root surfaces. (AB) A slight increase in the width of the apical periodontal space over the resected root surface but less than twice
the width of noninvolved parts of the root. (AC) A small defect in the lamina dura surrounding the root-end filling. (AD) Complete bone repair with discernible lamina dura; the bone
bordering the apical area does not have the same density as surrounding noninvolved bone. Complete bone repair. Hard tissue covering the resected root-end surface completely. (AE)
No apical periodontal space can be discerned. (B) Penn criteria for evaluating 3-dimensional scans of teeth after EMS. Limited healing categories. (BA) The continuity of the cortical
plate is interrupted by an area of lower density. (BB) A low-density area remains asymmetrically located around the apex or has an angular connection with the periodontal space. (BC)
Bone has not fully formed in the area of the former access osteotomy. (BD) The cortical plate is healed, but bone has not fully formed in the site. (C) Penn criteria for evaluating
3-dimensional scans of teeth after endodontic microsurgery. Unsatisfactory healing. The volume of the low-density area appears enlarged or unchanged.

JOE  Volume -, Number -, - 2019 Endodontic Microsurgery Using MTA and RRM 5
palpation, and periodontal probing. A
limited-volume CBCT scan was acquired at
least 1 of the follow-up visits with patient’s
consent. The patient’s longest follow-up on PA
radiography, CBCT imaging, and clinical
examination was included in the investigation.
The minimum follow-up period for all cases
was 12 months. The investigator was blinded
to the material used.
The following data from the follow-up
visits were extracted and assessed during
blinded radiographic and CBCT evaluation:
1. The type of root-end filling material:
MTA or RRM
2. The depth of material: equal to and
,2.5 mm or less measured on CBCT
imaging
3. The detection of an apical root fracture
intraoperatively that was eliminated
during root resection: notes
4. The presence of missed unfilled canals
that were addressed only surgically:
from CBCT imaging
5. Whether the tooth serves as a fixed
prosthetic bridge abutment
6. The presence or absence of
interproximal contacts
7. A full-coverage crown or buildup
Outcome Assessment
Clinical examination at the follow-up visits was
performed by 1 operator (C.S.). Three
calibrated examiners reviewed all the
radiographic images (B.K., S.K., and M.K.).
They are experienced endodontists familiar
with EMS. The examiners were blinded to the
material used and to the time of follow-up. A
specific score was assigned for each case
when all 3 examiners agreed or achieved a
consensus after discussion. The preoperative,
postoperative, and follow-up PA radiographs
were projected on a big screen in a dark room
and were displayed in a random fashion.
Two-dimensional healing on PA radiography
was determined as complete, incomplete,
uncertain, or unsatisfactory according to the
criteria established by Rud et al20 and Molven
et al21 (Fig. 2A–C).
Each patient had 1 preoperative CBCT
scan and 1 follow-up CBCT scan. Images were
projected in a dark room, and Digital Imaging and
Communications in Medicine files of the CBCT
scans were viewed using OsiriX (Pixmeo,
Geneva, Switzerland) in the multiplanar
reconstruction mode with high-definition
projection. The axes were aligned to obtain ideal
mesiodistal and buccolingual sections; the
sagittal plane was parallel to the mesiodistal long
axis of the tooth, the coronal plane was aligned
along with the root canal, and both planes
passed through the middle of the resected root-
6 Safi et al.
end surface. The slice thickness was set to
0.125 mm. After proper alignment, healing was
evaluated using the modified Penn 3-dimensional
criteria as described by Schloss et al22 (Fig. 3).
Results obtained were dichotomized into
healed and nonhealed categories. Cases
classified under complete or incomplete healing
on PA evaluation, complete healing, and limited
healing on CBCT evaluation with absence of
clinical signs and/or symptoms were regarded
as healed (successful), whereas those classified
as uncertain or unsatisfactory on PA
radiography and unsatisfactory healing on
CBCT imaging with or without clinical signs and
symptoms were labeled as nonhealed (failure). If
symptoms were noted at the follow-up visit, the
case was considered a failure irrespective of PA
or CBCT presentations.
Statistical Analysis
Significant association between PA and CBCT
imaging was assessed using the Cohen kappa
test. Significant associations between the
outcome and prognostic factors were
examined using the Fisher exact test. All
statistical tests were performed as 2-tailed with
the level of significance set at P , .05. Statistical
tests were performed using the R software
package v3.1.0 (http://www.r-project.org).
RESULTS
From the 243 teeth that were randomized and
underwent a microsurgical procedure, 122
teeth were examined at follow-up. A total of 57
teeth were examined from the MTA group and
65 teeth from the RRM group. One hundred
fourteen failed to attend any of the follow-up
visits. Seventeen other patients when
contacted over the phone indicated that the
tooth had been extracted. However, these
patients could not recall nor come to the
department for a clinical follow-up in order to
assess the reason for extractions. The reason
could be restorative, surgical, or periodontal
failure. These cases were considered lost to
follow-up, bringing the total number lost to
follow-up to 121. Among the 122 teeth that
were examined, 2 teeth were eliminated
because of procedural errors as seen on
follow-up CBCT imaging but not detected on
PA radiographs. The final sample consisted of
120 teeth. The mean follow-up time was 15
months (Fig. 1).
The overall success rate as per
2-dimensional PA radiography was 93.3% with
a success rate of 94.7% for MTA and 92% for
RRM, which was not statistically significant.
The combined success rate on CBCT
evaluation was 85% with a success rate of
86% for MTA and 84% for RRM, respectively.
Overall, there was substantial agreement
(92.5%) between PA scores and CBCT scores
(Cohen kappa 5 0.63; 95% confidence
interval [CI] 5 0.397–0.862; P , .001) when
using the data for both materials.
Microsurgical classification (A, B, or C)
(P 5 .019; odds ratio 5 6.2; 95% CI,
1.231–31.346) and the depth of root-end filling
material (2.5 mm or less measured on CBCT
imaging) (odds ratio 5 50; 95% CI,
9.363–706.502) had a significant influence on
PA outcome. Root canal filling quality
(adequate or inadequate) (P 5 .035; odds ratio
5 9; 95% CI, 1.378–62.091), depth of
root-end filling material (odds ratio 5 14; 95%
CI, 4.234–48.631), and the presence of a root
fracture (P 5 .02; odds ratio 5 23.2; 95% CI,
1.778–302.645) detected intraoperatively even
if eliminated during the resection were the
prognosis factors with a significant influence
on CBCT outcome. None of the other
prognostic criteria had a statistically significant
influence on the outcome of EMS whether
assessed on PA or CBCT imaging.
The 2 teeth that were eliminated from
the data set had incomplete root resection that
was detected on the follow-up CBCT scan.
Both cases had RRM as the root-end filling
material. None of the MTA-treated teeth had
any procedural errors observed on follow-up
CBCT imaging.
DISCUSSION
EMS is a predictable procedure with a high
success rate when either MTA or RRM are used
as a root-end filling material15–17. In the current
investigation, the outcome was not found to be
significantly different between the 2 materials
when healing was evaluated with either 2-
dimensional PA radiography or 3-dimensional
CBCT imaging. The overall success rates for
MTA and RRM cases on 2-dimensional PA
radiography were 94.7% and 92%,
respectively. These values are comparable with
other studies in which successful healing after
surgery has been reported to be 90.2%–95.6%
for MTA and 92%–94.4% for RRM16,17,23. The
statistical analysis showed no difference
between the 2 materials similar to the results of
Zhou et al clinically17 and Chen et al in the
animal model15.
Two-dimensional imaging with PA
radiography lacks sensitivity in detecting apical
periodontitis and minute changes in
periodontal ligament reformation24,25. Few
studies have compared PA versus CBCT
healing after surgery with a follow-up
period ranging from 4–12 months
postoperatively26–28. The results of these
investigations concluded that CBCT imaging
shows lower healing than PA radiography in
the time investigated. The results of the current
JOE  Volume -, Number -, - 2019
 study suggest a similar pattern. Von Arx et al26 RRM was at an inadequate depth, there was a

Unsatisfactory

Unsatisfactory
showed that nearly a third of cases had less significant association with failure on PA
healing on CBCT imaging than PA at the radiography (P 5 .04) and CBCT imaging

15.9
15.9
0
1-year follow-up. Similarly, Christiansen et al27 (P 5 .007). Because the depth of the root-end
in their evaluation of 58 teeth with a CBCT scan filling correlates with a proper seal, it can be

7.9
1 week and 1 year after surgery detected 28% speculated that for MTA and RRM to seal it
more defects on CBCT imaging than PA should have a minimal depth of 2.5 mm or more.
Uncertain

An interesting intraoperative finding of

BCRRM
radiography. In the current evaluation, the
7.9

Limited
BCRRM

difference in value between the completely this investigation is the presence of an apical

36.5
healed category in PA radiography versus root fracture. Even though it was eliminated
CBCT imaging has a similar discrepancy in the during surgery, teeth with a root fracture were
Complete Incomplete

84.1 range of 25%. Completely healed teeth on 23 times more likely to fail on CBCT imaging at
20.6

CBCT imaging was 50% compared with 74% follow-up. It has been speculated that the use
on PA radiography (Table 2). Chen et al15
Complete

of ultrasonics during retrograde preparation

92.1

47.6

showed superior CBCT and micro–computed could induce and propagate microcracks in
tomographic healing with RRM compared with dentin30. The finding of this investigation might
71.5

MTA in an animal investigation, whereas our suggest that despite the microscopic
TABLE 2 - The Distribution of Cases according to Their Scores on Periapical (PA) Radiography and Cone-beam Computed Tomographic (CBCT) Imaging as a Function of Time

results show no difference between the 2 elimination of the crack by further resection of
materials on CBCT evaluation. the root, microcracks may remain and can
Unsatisfactory

Microsurgical classification was a propagate, compromising healing. It was

Unsatisfactory

significant preoperative prognostic factor. coincidental that all the roots that had fractures
14.1
14.1

Among classification A, B, and C, there was a were chosen by random selection to be filled
1.7

6 times greater probability of detecting a failure with MTA.

on PA when the classification was C (P 5 Two cases were eliminated for
5.2

.019). One can speculate that the healing time procedural errors as detected on follow-up
Uncertain

for classification C (a large lesion occupying the CBCT imaging. The obvious failure was
3.5

apical half) is longer than for classification A (no caused by the incorrect execution of EMS and
MTA
Limited
33.3

lesion) or B (a small lesion occupying the apical leakage associated with an incorrectly done
MTA

quarter). In their comparison of 2 materials, procedure. It was not a true failure of EMS or
Zhou et al17 reported a lower outcome when the root-end filling material. These cases
Complete Incomplete

85.9

the lesion was larger than 5 mm. Von Arx underwent resurgery in the clinic to correct the
10.5

et al’s29 meta-analysis of outcome of drawback. As allowed in the Consolidated

Complete

BCRRM, bioceramic root repair material; CBCT, cone-beam computed tomographic; MTA, mineral trioxide aggregate.

microsurgery concurred with the study by Standards of Reporting Trials guidelines, these
94.8

52.6

Zhou et al. Both question the kinetics of healing cases were not representative of EMS and
of a large lesion and whether histologically hence at the point of CBCT analysis at
84.3

larger lesions show scar tissue healing and follow-up were eliminated from the data set.
hence a corresponding area of low density on Although every attempt was made to
radiographic evaluation. have all patients enrolled in the study followed
Unsatisfactory
Unsatisfactory

Another significant preoperative up, 52% returned. Because of the final sample
prognostic factor was root canal filling quality. size of the investigation, the CI of the results
15
15
5

There was a 9 times greater chance to see was wide. Three different CBCT machines
failure on CBCT imaging when the quality of were used in this study. Whether the use of
6.7

the filling was inadequate (P 5 .035). This different machines led to a difference in the
suggests that inadequate root canal fillings can evaluation of prognosis needs further research.
Uncertain

function as a microbial reservoir and The strength of the present study is

Teeth
1.7

randomization of root-end filling material,

Limited

compromise the sealing effect of MTA and

33.3
Teeth

RRM. When root canal filling was deemed blinded operators and examiners to type of
inadequate in length and density, it was a root end-filling material, and the time of
Complete Incomplete

prognostic factor of consequence in other follow-up. MTA and RRM have similar
85
17.5

studies as well17,29. On the other hand, radiodensity. In our experience, it is not

Complete

whether the tooth had been retreated before radiographically distinguishable. The
93.3

51.7

surgery or not was not found to be a significant examiners were not informed which material
factor16. was being evaluated either. The randomization
The depth of the root-end filling material procedure ensures that groups had an even
75.8

was also a significant postoperative prognostic distribution of known and unknown

factor. In general, having an inadequate depth confounding factors.
CBCT scores (%)

resulted in failure on PA and CBCT imaging.

Success–failure

Success–failure
PA scores (%)

When MTA was at an inadequate depth, there

was a significant association with failure on PA
radiography (P 5 .001). Cases with an
inadequate MTA depth were 18 times more
likely to fail on CBCT imaging (P 5 .003). When
CONCLUSION
In this prospective randomized controlled
study, there was no significant difference in the
outcomes of EMS when MTA and RRM were

JOE  Volume -, Number -, - 2019 Endodontic Microsurgery Using MTA and RRM 7
used as root-end filling materials. RRM is a ACKNOWLEDGMENTS Supported and conducted
valid and suitable material for root-end filling. independently by the Department of
The authors thank Dr Fouad Al-Malki, Ms Anya
Microsurgical classification, root canal filling Endodontics, University of Pennsylvania,
Kohli in making the illustrations and figures for
quality, depth of root end-filling material, and Philadelphia, PA.
the article, and Christel Chehoud for help with
the presence of a root fracture significantly The authors deny any conflicts of
statistical analysis.
affected the outcome. interested related to this study.

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